CHAPTER

The Normal Chest

12

Simon Padley and Sharyn L. S. MacDonald

The lungs The central airways The lungs beyond the hila The hila The mediastinum The diaphragm

THE LUNGS
Each lung is divided into lobes surrounded by pleura. There are two lobes on the left: the upper and lower, separated by the major (oblique) fissure; and three on the right: the upper, middle and lower lobes separated by the major (oblique) and minor (horizontal) fissures. The fissures are frequently incomplete, particularly medially, containing localized defects which form an alveolar pathway for collateral air drift and the spread of disease. For a fissure to be visualized on conventional radiographs, the X-ray beam has to be tangential to the fissure. In most people, some or all of the minor fissure is seen in the frontal projection, but neither major fissure can be identified. In the lateral view, both the major and minor fissures are often identified, but usually only part of any fissure is seen; in fact, it is very unusual to see both left and right major fissures in their entirety. The major fissures have similar anatomy on the two sides. They run obliquely anteriorly and inferiorly from approximately the fifth thoracic vertebra to pass through the hilum and contact the diaphragm 03 cm behind the anterior costophrenic angle. Each major fissure follows a gently curving plane somewhat similar to a propeller blade (Fig. 12.1), with the upper portion facing anteriorly and laterally, and the lower portion facing forward and medially. Owing to the undulating course of the major fissure, either fissure may be seen as two lines on the lateral view. Consequently it may appear to the unwary that a fissure is displaced when it is in fact in its normal position, or both fissures may appear to be in their normal positions when in reality one of them is so displaced that it is no longer visible.

The inferior few centimetres of either or both major fissures may be widened owing to the presence of fat or pleural thickening between the leaves of the pleura. In these circumstances the contact with the diaphragm will often be broadened and lead to a localized loss of silhouette, an appearance referred to as the juxtaphrenic peak. With modern multislice computed tomography (CT), the normal major fissures are frequently visible, but if not clearly defined the position can be inferred from the presence of a relatively avascular zone that forms the outer cortex of the lobe. With high-resolution CT (HRCT), a normal major fissure is seen as a thin line traversing the avascular zone1, although it may be represented as two parallel lines on at least one level in approximately one-third of the population because of an artefact related to cardiac and respiratory motion2. The minor fissure fans out anteriorly and laterally from the right hilum in a horizontal direction to reach the chest wall. On a standard chest radiograph, the minor fissure contacts the chest wall at the axillary portion of the right sixth rib. The fissure curves gently, with its anterior and lateral portion usually curving downwards. Because of the curvature of the major fissure described above, part of the minor fissure may be projected posterior to the right major fissure on the lateral view. On CT the minor fissure position is represented by an oval area of reduced vascularity at the level of the bronchus intermedius (Fig. 12.2). The normal minor fissure is not seen as a line on axial CT imaging but is apparent on multiplanar reformats. In 1% of the population an accessory fissure3 called the azygos lobe fissure (Fig. 12.3) is seen. This fissure contains the azygos vein at its lower end and results from failure of normal migration of the azygos vein from the chest wall to its usual position in the tracheobronchial angle and persistence of the invaginated visceral and parietal pleurae.There is no corresponding alteration in the segmental architecture of the lung, so the term lobe is a misnomer. The azygos lobe may, however, be smaller and therefore less transradiant than corresponding normal lung4. On CT the altered course of the azygos vein can be seen traversing the lung (Fig.12.3B).

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Figure 12.1 The different position and shape of the major fissures (arrows) in the lower and the upper zones is well shown by CT. Note that (A) below the hila, the major fissures bow forward, whereas (B) above the hila, the major fissures bow backward. (The images are high-resolution thin-section [1.5 mm] CT scans.) Sagittal reformats from the (C) right and (D) left lungs demonstrate the detail of fissure anatomy available on this 16-channel CT study.

Figure 12.2 Minor fissure on CT. (A) The minor fissure is apparent as an area of avascularity anterior to the major fissure. In this example the slightly bowed horizontal fissure undulates through the plane of the slice. (B) The position of the minor fissure, in another patient, is indicated by the oval deficiency of vessels in the right mid zone (arrows).

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Figure 12.3 (A) Azygos lobe fissure (curved arrows) and aortic nipple (horizontal straight arrow). The azygos vein in the lower end of the fissure is well seen (lower curved arrow). Note its absence from its usual location in the right tracheobronchial angle (open arrow). The aortic nipple, due to the left superior intercostal vein, is particularly large in this example. (B) CT of the azygos lobe fissure.

Other accessory fissures are occasionally identified3. A minor fissure may separate the lingular segments from the remainder of the upper lobe, similar to the right minor fissure. A horizontally orientated fissure, a superior accessory fissure, may separate the apical segment from the basal segments of either lower lobe. An inferior accessory fissure is sometimes seen in one or other lower lobe, usually the right, separating the medial and anterior basal segments. This fissure runs obliquely upward and medially towards the hilum from the diaphragm. The inferior pulmonary ligaments5 are pleural reflections from the mediastinum which hang down from the hila and are analogous in shape to the peritoneal reflections forming the broad ligament of the uterus. These two layers of pleura may extend down to the diaphragm or may have a free inferior edge. The intersegmental septum of the lower lobe, a septum within the lung immediately beneath the inferior pulmonary ligament, is often visible on CT (Fig. 12.4)6.When the inferior pulmonary ligament reaches the diaphragm it may contain a small amount of fat. This may efface the diaphragm, resulting in a juxtaphrenic peak. Otherwise neither the intersegmental septum nor the inferior pulmonary ligament is visible on plain radiographs.

Figure 12.4 Intersegmental septum deep to the inferior pulmonary ligament shown by CT (arrows).

THE CENTRAL AIRWAYS

The trachea is a straight tube that, in children and young adults, passes inferiorly and posteriorly in the midline. In subjects

with unfolding and ectasia of the aorta the trachea may deviate to the right and may also bow forward. In cross-section the trachea is usually round, oval, or oval with a flattened posterior margin. Maximum coronal and sagittal diameters in adults on plain chest radiography are 21 and 23 mm, respectively, for women, and 25 and 27 mm for men7. On CT, which allows precise assessment of diameters and cross-sectional areas without magnification, the mean transverse diameter is 15.2 mm (sd 1.4) for women and 18.2 mm (sd 1.2) for men,

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the lower limit of normal being 12.3 mm for women, and 15.9 mm for men8. The diameters in growing children and young adults have been documented9. Calcification of the cartilage rings of the trachea is a common normal finding after the age of 40 years, increasing in frequency with age. The trachea divides into the two mainstem bronchi at the carina. In children the angles are symmetrical, but in adults the right mainstem bronchus has a steeper angle than the left. The range of angles is wide, and alterations in angle can be diagnosed only by rightleft comparisons, not by absolute measurement. The left main bronchus extends up to twice as far as the right main bronchus before giving off its upper lobe division. The lobar and segmental branching pattern is shown in Figure 12.5. There are many variations of the segmental and subsegmental branches10,11. Airways to subsegmental level can be routinely identified on volumetric thin-collimation CT.

THE LUNGS BEYOND THE HILA

The usual method of deciding normal lung density in the frontal view is by comparison with equivalent areas on the opposite side. Since this is not possible on the lateral chest radiograph, the detection of subtle densities is more difficult, but the density over the spine should decrease gradually as the eye travels down the spine until the diaphragm is reached. Certain other comparisons can be made, but are less reliable: the density of the high retrosternal areas is approximately equal to that of the area immediately posterior to the left ventricle; the density over the heart is usually similar to that over the shoulders; and, apart from the cardiac fat pads and overlying ribs, there should be no abrupt change in density over the heart shadow. The segmental bronchi divide into smaller and smaller divisions until after 620 divisions they become bronchioles and

Figure 12.5 Diagram illustrating the anatomy of the main bronchi and segmental divisions. The nomenclature is that approved by the Thoracic Society. (Courtesy of the Editors of Thorax.)

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no longer contain cartilage in their walls. The bronchioles divide and the last of the purely conducting airways are known as the terminal bronchioles, beyond which lie the alveoli. The walls of the segmental bronchi are invisible on the chest radiograph unless seen end-on, when they may cause ring shadows (Fig.12.6). The acinus, which is 56 mm in diameter, comprises respiratory bronchioles, alveolar ducts and alveoli. The acini are grouped together in lobules of three to five acini which, in the lung periphery, are separated by septa and together comprise

Figure 12.6 Ring shadows (arrows) due to end-on bronchi as a normal finding on chest radiography. The patient has a dual chamber pacing system.

the secondary pulmonary lobule.These peripheral interlobular septa, when thickened by disease, are the so-called septal or Kerley B lines. The bronchopulmonary segments are based on the divisions of the bronchi.The boundaries between segments are complex in shape and have been likened to the pieces of a three-dimensional (3D) jigsaw puzzle; there is no septation between them (except in the rare instance of a patient with accessory fissures). Atelectasis or pneumonia may predominate in one or other segment, but rarely conforms precisely to the whole of just one segment, since collateral air drift occurs across the segmental boundary. The position of the segments as seen on standard radiographs is illustrated in Figure 12.7. The pulmonary blood vessels (Fig. 12.8) are responsible for branching linear markings within the lungs both on conventional radiographs and CT. It is not possible to distinguish arteries from veins in the outer two-thirds of the lungs on plain radiographs. Centrally, the orientations of the arteries and veins differ: the lower lobe veins run more horizontally and the lower lobe arteries more vertically. In the upper lobes, the arteries and veins show a similar gently curving vertical orientation, but the upper lobe veins (when not superimposed on the arteries) lie lateral to the arteries and can sometimes be traced to the main venous trunk, the superior pulmonary vein. The diameter of the blood vessels beyond the hilum varies with the position of the patient and with various haemodynamic factors. On plain chest radiographs taken in the upright position, there is a gradual increase in the relative diameter of vessels equivalent in distance from the hilum as the eye travels from apex to base.The differences are abolished when the patient lies supine. These observations correlate

1 2 3 4 5 H

6 10 H 7 8 12 9 14 13 H 11 18 H 15 16 17

6 1 2 3 H 4 5 12 11 13 14 18 17 16 9 7 10 15 H v

Figure 12.7 Diagrams of position of segments seen on plain frontal and lateral chest radiographs. There is substantial overlap of the projected images of the segments in both views; this overlap is worse in the frontal than the lateral projection. (A) Shows only the segments in the upper lobes and the middle lobe; (B) shows only the segments in the lower lobes; (C,D) show all the segments in the right and left lung, respectively, in the lateral view. H = hila, 1 = apical segment of right upper lobe (RUL), 2 = posterior segment of RUL, 3 = anterior segment of RUL, 4 = lateral segment of right middle lobe (RML), 5 = medial segment of RML, 6 = apical posterior segment of left upper lobe (LUL), 7 = anterior segment of LUL, 8 = superior segment of lingula, 9 = inferior segment of lingula, 10 = apical (superior) segment of right lower lobe (RLL), 11 = medial basal segment of RLL, 12 = anterior basal segment of RLL, 13 = lateral basal segment of RLL, 14 = posterior basal segment of RLL, 15 = apical (superior) segment of left lower lobe (LLL), 16 = anterior basal segment of LLL, 17 = lateral basal segment of LLL, 18 = posterior basal segment of LLL.

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Figure 12.8 Pulmonary angiogram shows appearances in (A) arterial phase and (B) venous phase. Note the difference in arrangement of the central arteries and veins. The peripheral arteries show similar anatomy to the peripheral veins. (C) Coronal maximum intensity projection slab image from a CT pulmonary angiogram demonstrating the combined arterial and venous phase image in a patient with normal circulation.

with physiological studies of perfusion which show that in the erect position there is a gradation of blood flow (the lower zones showing greater blood flow than the upper zones) from apex to base, a difference that is less obvious in the supine patient. While a general statement regarding these differences in zonal blood vessel size can be made, it is difficult to draw conclusions from the size of any particular peripheral pulmonary vessel. Certain measurements have, however, been suggested for upright chest radiographs: 1 The artery and bronchus of the anterior segment of either or both upper lobes are frequently seen end-on.The diameter of the artery is usually much the same as the diameter of the bronchus (45 mm). In the authors experience, an endon vessel with a diameter of over 1.5 times the diameter of the adjacent bronchus indicates that the vessel is increased in size. 2 Vessels in the first anterior interspace should not exceed 3 mm in diameter. A rich network of lymphatic vessels drains the lung and pleura to the hilar lymph nodes. The sub-pleural lymphatics are found beneath the pleura at the junction of the interlobular septa with the pleura. These vessels connect with each other and with the lymphatic vessels accompanying the veins in the interlobular septa. Lymph then flows to the hilum via deep lymphatic channels that run peribronchially and in the deep septa of the lungs. Under normal circumstances the lymphatic network is invisible radiographically but when thickened the septa are seen as line shadows known as septal or Kerley lines. Thickened interlobular septa correspond to Kerley B lines and thickened deep septa correspond to Kerley A lines. There are a few intrapulmonary lymph nodes, but they are small and cannot be identified on a chest radiograph but may be seen as small, peripherally located ellipsoid nodules on CT12,13.

THE HILA
Understanding the normal hilum on plain radiography, CT and magnetic resonance imaging (MRI) requires an appreciation of the anatomy of the major blood vessels (Figs 12.912.13). On plain radiograph and CT the densities of the normal hilum are due mainly to blood vessels (Figs 12.1012.12). Normal lymph nodes cannot be recognized as discrete structures, and the bronchial walls contribute little to the bulk of the hila, being thin and easily recognized for what they are. On MRI (Fig. 12.13), the lack of signal from fast-flowing blood within the vessels or from air in the bronchi means that there is relatively little signal generated from normal hilar structures on standard spin-echo sequences. The only signal will be from slow-flowing blood in the vessels, from the bronchial walls, and from the fat and hilar nodes. Normal lymph nodes of just a few millimeters in size are often evident as discrete structures on submillimeter collimation multislice CT. The major points to remember when viewing the hila are: 1 The transverse diameter of the lower lobe arteries before their segmental divisions can be determined with reasonable accuracy: they measure 916 mm on the normal postero-anterior (PA) chest radiograph (Fig. 12.11). 2 The posterior walls of the right main bronchus and its division into the right upper lobe bronchus and bronchus intermedius are outlined by air and appear as a thin stripe on lateral plain radiographs (Fig. 12.14) and on CT (Fig. 12.12).The posterior walls of the equivalent bronchi on the left are rarely visible on the plain radiograph because the left lower lobe artery intervenes between the lung and the bronchial tree. The lung does, in fact, frequently invaginate between the left lower lobe artery and the descending aorta to contact the posterior wall of the left lower lobe bronchus, but this is usually only visible on CT or MRI. 3 The right pulmonary artery passes anterior to the major bronchi, whereas the left pulmonary artery arches superior to the left main bronchus. The central portion of the right

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Figure 12.9 Diagrams of the relationships between the hilar blood vessels and bronchi. (A) Frontal view. (B) Right posterior oblique view of right hilum. (C) Left posterior oblique view of left hilum. (D) Lateral chest radiograph with major blood vessels drawn in. IPV = inferior pulmonary veinonly one has been drawn in since they are superimposed, LPA = left pulmonary artery, LSPV = left superior pulmonary vein, RPA = right pulmonary artery; RSPV = right superior pulmonary vein. (Diagrams drawn by Ron Ervin and reproduced with permission from Armstrong P (ed) 1983 Critical problems in diagnostic radiology. Lippincott, Philadelphia.)

Figure 12.10 Normal digital PA chest radiograph demonstrating position and density of the hilar structures. Arrows indicate the hilar points, where the superior pulmonary vein crosses the descending lower lobe artery, the left normally being level with or slightly higher than the right.

Figure 12.11 Frontal view of hila in plain chest radiograph. The measurement points for the diameter of the right lower lobe artery are indicated.

Figure 12.12 CT of normal hila. Two-millimetre collimation images have been obtained through the hilar structures during contrast medium enhancement and displayed on lung windows (L-500, W 1500). (A) Section just below the tracheal carina at the origin of the right upper lobe bronchus, immediately posterior to the upper lobe vein (v). (B) Section through level of right main pulmonary artery (RPA) and bronchus intermedius (curved arrow). Note the tongue of lung that contacts the left main bronchus between the aorta (A) and the left lower lobe artery (straight arrow). Note also that the right lung contacts the posterior wall of the bronchus intermedius as it extends into the azygo-oesophageal recess. (C) Section through the level of the middle lobe bronchus (long arrow) at the point of origin of the bronchus to the superior segment of the right lower lobe (arrow). Note that the middle lobe bronchus separates the right lower lobe artery from the right superior pulmonary vein as it enters the left atrium (LA). The lung contacts the posterior wall of the right lower lobe bronchus as it extends into the azygo-oesophageal recess. (D) Section through the level of the inferior pulmonary veins (arrows). At this level the lower lobe arteries have bilaterally divided into basal segmental divisions and are therefore narrower than 1 cm in diameter.

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5 The pulmonary veins are similar on the two sides.The superior pulmonary vein is the anterior structure in the upper and mid hilum on both sides. Since, however, the central portions of the pulmonary arteries are so differently organized on the two sides, the relationships of the major veins to the arteries differ. On the right the superior pulmonary vein is separated from the central bronchi by the lower division of the right pulmonary artery, whereas on the left the superior pulmonary vein is separated from the pulmonary artery by the bronchial tree. Both inferior pulmonary veins travel obliquely anteriorly and superiorly, inferior to the branches of the left lower lobe artery, to enter the left atrium. They are slightly posterior to the plane of the left lower lobe bronchi. They may be seen either end-on or in oblique cross-section in PA, lateral and oblique projections and may, therefore, simulate a mass.

Figure 12.13 MRI of normal hilum. Note that there is relatively little signal from the hila because there is no signal either from air in the bronchial tree or from fast-flowing blood in the pulmonary artery or vein branches.

THE MEDIASTINUM
The radiographic anatomy of the mediastinum can be described from many points of view, depending on the technique that is under discussion. In this chapter only plain radiographs, CT and MRI will be considered in any detail, CT and MRI being illustrated first because an appreciation of the cross-sectional anatomy of the mediastinum helps in understanding the appearances on plain chest radiographs. The mediastinum is conventionally divided into superior, anterior, middle and posterior compartments. The exact anatomical boundaries of these divisions are unimportant to the radiologist (indeed they vary according to different authors), since they do not provide a clear-cut guide to disease and nor do their boundaries form any barriers to the spread of the disease.

Computed tomography and magnetic resonance imaging

The blood vessels, trachea and main bronchi make up the bulk of the mediastinum, and the CT/MRI anatomy of these structures is illustrated in Figures 12.1212.16. The thymus is situated anterior to the aorta and right ventricular outflow tract or pulmonary artery; it is often best appreciated on a section through the aortic arch or great vessels (Fig. 12.17). Before puberty15 the thymus fills in most of the mediastinum in front of the great vessels. During this period of life the gland varies so greatly in size that measurement is of little value in deciding normality. Approximate symmetry is the rule. Also, the thymus fills in the spaces between the great vessels and the anterior chest wall as if moulded by these structures. In adults the thymus is bilobed or triangular in shape. The maximum width and thickness of each lobe decreases with advancing age. Between the ages of 20 and 50, the average thickness as measured by CT decreases from 89 mm to 56 mm, the maximum thickness of each lobe being up to 15 mm. These diameters are greater on MRI, presumably because MRI demonstrates the thymic tissue even when it is partially replaced by fat. On MRI, sagittal images demonstrate the gland to be 57 cm long in its craniocaudad dimension.

Figure 12.14 Lateral view of the hila showing normal thickness of the posterior wall of the bronchus intermedius (arrow).

hilum consists of a combination of the right pulmonary artery and the superior pulmonary vein. Since these two vessels are immediately adjacent to one another (on the left, the left main bronchus lies between them), they may be responsible for a density that is sufficiently great to be confused with a mass on lateral plain radiographs and even, on occasion, on CT. 4 On lateral chest radiographs the angles between the middle and right lower lobe bronchi on the right, and the upper and lower lobe bronchi on the left, do not contain any large end-on vessels; a rounded shadow of greater than 1 cm in these angles is therefore unlikely to be a normal vessel14.

Figure 12.15 CT of normal mediastinum. (AE) Five 1-cm thick sections have been selected to show the important anatomical features. The level of each section is illustrated in the diagram. A. Ao = ascending aorta, Ao arch = aortic arch, AV = azygos vein, D. Ao = descending aorta, IA = innominate artery, LA = left atrium, LCA = left carotid artery, LIV = left innominate vein, LPA = left pulmonary artery, LSA = left subclavian artery, MPA = main pulmonary artery, N = normal lymph node, OES = oesophagus, RA = right atrium, RIV = right innominate vein, RPA = right pulmonary artery, RVO = right ventricular outflow tract, SPV = superior pulmonary vein, SVC = superior vena cava, T = trachea.

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Figure 12.16 MRI of normal mediastinum and hila. Four sections have been chosen to show the important anatomical features: (A) is just below the tracheal carina; (B) is 1 cm below A; (C) is at the level of the right main pulmonary artery; (D) is at the level of the mid left atrium. A.Ao = ascending aorta, AV = azygos vein, BI = bronchus intermedius, D.Ao = descending aorta, LA = left atrium, LMBr = left main bronchus, LPA = left pulmonary artery; LV = left ventricle, MPA = main pulmonary artery, Oes = oesophagus, RA = right atrium, RMBr = right main bronchus, RSPV = right superior pulmonary vein, SPR = superior pericardial recess, SVC = superior vena cava, Th = thymus.

Figure 12.17 CT of normal thymus (arrows) in a young adult man.

In younger patients, the CT density of the thymus is homogeneous and close to that of other soft tissues, but after puberty the density gradually decreases owing to fatty replacement, so that above 40 years of age the thymus usually has an attenuation value identical to that of fat and is often indistinguishable from the adjacent mediastinal fat, apart from some residual thymic parenchyma which may be visible as streaky or nodular densities within the fat (Fig. 12.18)16,17. On MRI the intensity of the thymus in T1weighted images is similar to that of muscle and appreciably lower than that of mediastinal fat, although, as would be expected, this difference decreases with age. On T2weighted images, the intensity differences are slight and do not vary with age.

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Figure 12.18 Thymic residues (arrows) shown by CT.

Figure 12.19 Diagram showing AJCCUICC classification of regional lymph nodes.

Lymph nodes are widely distributed in the mediastinum. Ninety-five per cent of normal mediastinal lymph nodes are less than 10 mm in diameter, and the remainder, with few exceptions, are less than 15 mm in diameter1822. Lymph nodes in the paraspinal areas, in the region of the brachiocephalic veins and in the space behind the diaphragmatic crura are generally smaller, 6 mm or less, whereas nodes in the aortopulmonary window, pretracheal and lower paratracheal spaces, and subcarinal compartment are often 610 mm in diameter. Lymph nodes encircle the trachea and main bronchi except where the aorta, pulmonary artery, or oesophagus are in direct contact with the airway.There is no clear division between the various nodes, but they can be categorized according to site.

The nomenclature of mediastinal lymph nodes should accord with the terms agreed by the American Joint Committee on Cancer and the Union International Contre le Cancer (AJCC UICC) designed for staging carcinoma of the bronchus (Fig. 12.19; Table 12.1)23,24. These terms replaced the previous American Thoracic Society (ATS) classification. The AJCCUICC classification is based on cross-sectional imaging in that it is directly referable to axial cross-sectional anatomy. The plane tangential to the upper margin of the aortic arch is an important dividing plane with nodes above this level being designated as: highest mediastinal nodes (station 1 if they are above the upper rim of the left brachiocephalic vein); right, left and posterior upper paratracheal (stations 2R,

Table 12.1 AJCCUICC CLASSIFICATIONS OF REGIONAL LYMPH NODES

1. Highest mediastinal nodes lie above a horizontal line at the upper rim of the bracheocephalic (left innominate) vein 2. Upper paratracheal nodes lie above a horizontal line drawn tangential to the upper margin of the aortic arch and below the inferior boundary of No1 nodes 3. Prevascular and retrotracheal nodes may be designated 3A and 3P: midline nodes are considered to be ipsilateral 4. Lower paratracheal nodes lie to the right or left of the midline of the trachea between a horizontal line drawn tangential to the upper margin of the aortic arch and a line extending across the right or left main bronchus at the upper margin of the ipsilateral upper lobe bronchus. They are contained within the mediastinal pleural envelope. NB: The left lower paratracheal nodes lie medial to the ligamentum arteriosum 5. Subaortic (aortopulmonary window) nodes lie lateral to the ligamentum arteriosum or the aorta or left pulmonary artery and proximal to the first branch of the left pulmonary artery and lie within the mediastinal pleural envelope 6. Para-aortic nodes (ascending aorta or phrenic) lie anterior and lateral to the ascending aorta and the aortic arch or the innominate artery, beneath a line tangential to the upper margin of the aortic arch 7. Subcarinal nodes lie caudal to the carina of the trachea, but not associated with the lower lobe bronchi or arteries within the lung 8. Para-oesophageal nodes (below carina) lie adjacent to the right or left of the midline, excluding subcarinal nodes 9. Pulmonary ligament nodes lie within the pulmonary ligament, including those against the posterior wall and lower part of the inferior pulmonary vein 10. Hilar nodes lie distal to the mediastinal pleura reflection and the nodes adjacent to the bronchus intermedius on the right 11. Interlobar nodes lie between the lobar bronchi 12. Lobar nodes lie adjacent to the distal lobar bronchi 13. Segmental nodes lie adjacent to the segmental bronchi 14. Subsegmental nodes lie around the subsegmental bronchi
NB. Station 1 through 9 nodes lie within the mediastinal pleural envelope, whereas station 10 through 14 nodes lie outside the mediastinal pleura within the visceral pleura.

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2L and 3P, respectively); and prevascular if they lie anterior to the arteries to the head and neck (station 3A). The nodes below the plane tangential to the upper margin of the aortic arch include the following: right and left lower paratracheal (stations 4R and 4L); subaortic (aortopulmonary window) nodes (station 5); para-aortic nodes which lie anterior and lateral to the ascending aorta, the aortic arch, or the proximal brachiocephalic artery (station 6); and subcarinal nodes, which lie beneath the main bronchi within the mediastinal pleura (station 7). Low down in the mediastinum are the para-oesophageal (station 8) and pulmonary ligament nodes (station 9). Nodes are also present in the retrocrural areas and cardiophrenic angles. The nodes outside the mediastinal pleura are hilar (station 10), interlobar (station 11), lobar, segmental and subsegmental (stations 1214); all these nodes are removed at pneumonectomy. The oesophagus is visible on all axial CT and MRI sections from the root of the neck down to the diaphragm. It may contain a small amount of air in approximately 80% of normal people. If there is sufficient mediastinal fat, the entire circumference of the oesophagus can be identified, and if air is present in the lumen, the uniform thickness of the wall can be appreciated. Without air, the collapsed oesophagus appears circular or oval in shape and measures approximately 1 cm in its narrowest diameter. On MRI the signal intensity on T1-weighted images is similar to muscle but on T2-weighted images the oesophagus often shows much higher signal intensity than muscle.

Ant. junction line IA LCA Paratracheal stripe Posterior tracheal stripe Pleuro-oesophageal line SVC T Oesophagus Post. junction line LSA

Anterior junction line Ao Arch T Post. tracheal stripe Oesophagus

Paratracheal stripe

SVC

Pleuro-oesophageal line

Radiographic appearances
Plain chest radiographs provide limited information regarding mediastinal anatomy, since only the interfaces between the lung and the mediastinum are visualized (Fig. 12.20).

Junction lines25,26
When there is only a small amount of fat anterior to the ascending aorta and its major branches, the two lungs may be separated anteriorly by little more than the four intervening layers of pleura. In such patients an anterior junction line is visible on frontal chest radiographs (Fig. 12.21).The line diverges and fades out superiorly and cannot be identified above the level of the clavicles. It descends for a variable distance, usually deviating to the left, but never extending lower than the point where the two lungs separate to envelop the right ventricular outflow tract. The lungs may also come close together behind the oesophagus, forming the posterior junction line (Fig. 12.21). This line, unlike the anterior junction line, separates to envelop the aortic arch. It may reform below the aortic arch where the two lungs occasionally abut behind the oesophagus. Superiorly, the posterior junction line extends to the level of the lung apices where it diverges and disappears, a level appreciably higher than the medial ends of the clavicles. The differences in the superior extent of the anterior and posterior junction lines are related to the sloping boundary between the root of the neck and the thorax.
Azygo-oesophageal line Right paraspinal line Ao

Oesophagus

Azygos vein Left paraspinal line

Figure 12.20 Diagrams illustrating the mediastinal boundaries and junction lines. The visualization of the junction lines on a plain chest radiograph is variable, depending on how much fat is present in the mediastinum and on how closely the two lungs approximate to one another. (A) Section just above the level of the aortic arch; (B) section through the aortic arch; (C) section through the heart.

The major value of being able to identify the anterior and posterior junction lines is that a mass, or other space-occupying process, in the junctional areas can be excluded if these lines are visible. Since both junction lines are inconsistently seen, however, the lack of visualization of one or both is not a reliable sign of disease.

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Figure 12.22 Right tracheal stripe (straight arrows) and pleurooesophageal line (curved arrows) demonstrated on (A) plain radiograph and (B) unenhanced CT.

Figure 12.21 Anterior junction line (curved arrows) and the supraaortic posterior junction line (straight arrows). Note that the supraaortic posterior junction line goes well above the level of the clavicles and extends down to the top of the aortic arch but then stops, whereas the anterior junction line starts below the clavicles and continues well below the aortic arch.

the frontal projection. If the oesophagus at this level contains air, then the right wall of the oesophagus is seen as a stripe, the so-called oesophagealpleural stripe27, curving superiorly and laterally behind the tracheal air column (Fig. 12.22). In summary, on a frontal radiograph three interfaces are potentially recognizable in the right mediastinum above the azygos vein: the superior vena cava border, the right wall of the trachea, and the right wall of the oesophagus.

Right mediastinum above the azygos vein

The right superior mediastinal border is formed by the right brachiocephalic (innominate) vein and the superior vena cava. With aortic or brachiocephalic (innominate) artery ectasia or unfolding, either of these veins may be pushed laterally or the mediastinal border may be formed by the aorta or the right brachiocephalic artery. The right paratracheal region can be seen through the right brachiocephalic vein and superior vena cava because the lung contacts the right tracheal wall from the level of the clavicles down to the azygos vein, producing a visible stripe of uniform thickness known as the right paratracheal stripe (Fig.12.22), between the tracheal air column and the lung.This stripe, which should be no more than 5 mm wide, is visible in approximately two-thirds of normal people. It consists of the wall of the trachea and the adjacent mediastinal fat, but no focal bulges due to individual paratracheal lymph nodes can be seen. As with the junction lines, the diagnostic value of this stripe is that its presence excludes a spaceoccupying process in the area where the stripe is visible. The azygos vein is outlined by air in the lung at the lower end of the right paratracheal stripe. The diameter of the azygos vein in the tracheobronchial angle is variable: it may be considered normal when its diameter is 10 mm or less. The nodes immediately beneath the azygos vein are known as azygos nodes and are not recognizable on the normal chest radiograph. The lung posterior to the trachea contacts the right wall of the oesophagus so that a recognizable border may be seen in

Left mediastinum above the aortic arch

The mediastinal shadow to the left of the trachea above the aortic arch is of low density and is caused by the left carotid and left subclavian arteries together with the left brachiocephalic (innominate) and jugular veins. The usual appearance on the frontal projection is a gently curving border formed by the left subclavian artery, which fades out where the artery enters the neck. A separate interface may occasionally be discernible for the left carotid artery or left brachiocephalic vein. The outer margin of the left tracheal wall is virtually never outlined, because the lung is separated from the trachea by the aorta and other vessels listed above.

Trachea and retrotracheal area in the lateral view

The air column in the trachea can be seen throughout its length as it descends obliquely inferiorly and posteriorly. The course of the trachea on a normal lateral view is straight, or bowed anteriorly in patients with aortic unfolding, with no visible indentation from adjacent vessels. Small indentations into the air column of the trachea from tracheal cartilage rings may be apparent on the lateral view. The carina cannot be identified on the lateral view (though the right main bronchus is often mistaken for it). Its anterior wall is visible in a minority of patients, but the posterior wall is usually seen because lung often passes behind the trachea, thereby permitting visualization of the posterior tracheal (stripe) band28.The thickness of this stripe is 23 mm, provided it is formed solely by the tracheal wall and pleura (Fig. 12.23). If a large amount

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Figure 12.23 Lateral view of trachea and major bronchi. (A) In this example, the posterior wall of the trachea is outlined by lung posterior to it (arrow). (B) In this example, the collapsed oesophagus is between the lung and the trachea (arrow).

of air is present in the oesophagus, the posterior tracheal band may be much thicker, since it then comprises the combined thicknesses of the posterior tracheal wall and the anterior oesophageal wall. Alternatively, the lung may be separated from the trachea by the full width of a collapsed oesophagus, leading to a band of density measuring 10 mm or more (Fig. 12.23).

Supra-aortic mediastinum on the lateral view

A variable proportion of the aortic arch and its major branches is visible on the lateral view, depending largely on the degree of aortic unfolding. The brachiocephalic (innominate) artery is the only branch vessel that is recognizable with any frequency. It arises anterior to the tracheal air column; usually the origin is unclear but, after a variable length, the posterior wall can be seen as a gently S-shaped interface as it crosses the tracheal air column. The left and right brachiocephalic (innominate) veins are also sometimes visible on the lateral view. The left brachiocephalic vein is seen as an extrapleural bulge behind the manubrium in a small proportion of normal people (Fig. 12.24).

Figure 12.24 Bulge behind manubrium representing normal left innominate (brachiocephalic) vein (arrow).

Right middle mediastinal border below the azygos arch

Below the azygos arch, the right lower lobe makes contact with the right wall of the oesophagus and the azygos vein as it ascends next to the oesophagus. This portion of the lung is known as the azygo-oesophageal recess, and the interface is known as the azygo-oesophageal line (Fig. 12.25). The shape of the azygos arch varies considerably in different subjects and therefore the shape of the upper portion of the azygo-oesophageal line varies accordingly. The upper few centimetres of the azygo-oesophageal line are, however, always straight or concave toward the lung, so that a convex shape suggests the presence of a subcarinal mass or left atrial enlargement. The azygo-oesophageal line can be traced down to the posterior costophrenic angle in normal subjects.

Left cardiac border below the aortic arch

This left cardiac border is formed by the main pulmonary artery and heart. The pleura smoothing the angle between the mid-portion of the aortic arch and the main and left pulmonary artery, the so-called aorticpulmonary mediastinal stripe29, is the lateral extent of the aortopulmonary

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Figure 12.25 Azygo-oesophageal line (arrows).

Figure 12.26 Patterns of pleural reflection along the left border of the great vessels and heart. The heavy line indicates the visible pleural interface. (Adapted from Blank N, Castellino R A 1972 Patterns of pleural reflections of the left superior mediastinum: normal anatomy and distortions produced by adenopathy. Radiology 102: 585589, with permission from the Radiological Society of North America).

window. Because the aortopulmonary window is a sensitive place to look for lymph node enlargement, Blank and Castellino30 investigated the variable shape of this pleural reflection, as illustrated in Figure 12.26. A small nipple may occasionally be seen projecting laterally from the aortic knuckle owing to the presence of the left superior intercostal vein31,32 (see Fig. 12.3A). The vein, which is formed by the junction of the left first to fourth intercostal veins, arches forward around the aorta just below the origin of the left subclavian artery to enter the left brachiocephalic vein. This normal nipple should not be misinterpreted as adenopathy projecting from the aortopulmonary window. The interface between the lung and the left wall of the aorta can almost invariably be followed down to the level of the diaphragm, though contact with the proximal portion of the left pulmonary artery may silhouette a small portion of the interface.The shape varies with the degree of aortic unfolding. Though the lung invaginates between the heart and aorta to contact the left wall of the oesophagus, the interface with the oesophagus may be seen as a line if air is present within the lumen of the oesophagus.

undulations of the lateral spinal ligaments, but the more fat there is, the more these undulations are smoothed out. The thickness of the left paravertebral space is usually greater than that of the right and can be more than 10 mm in obese subjects. Aortic unfolding contributes to the thickness of the left paraspinal line; as the aorta moves posteriorly and laterally, it strips the pleura from its otherwise close contact with the profiled portions of the spine.

Retrosternal line
The band-like opacity simulating pleural or extrapleural disease is often seen along the lower third of the anterior chest wall on a lateral chest radiograph (Fig. 12.27)33. This density is due to mediastinal fat and to the differing anterior extent of the left and right lungs. The left lung does not contact the most anterior portion of the left thoracic cavity at these levels because the heart occupies the space. The band-like opacity is therefore accounted for by the normal heart and mediastinum, rather than by disease.

THE DIAPHRAGM
The diaphragm consists of a large dome-shaped central tendon surrounded by a sheet of striated muscle which is attached to ribs 7 to 12 and to the xiphisternum. The two diaphragmatic crura, which arise from the upper three lumbar vertebrae, arch superiorly and anteriorly to form the margins of the aortic

Paraspinal lines
Although lymph nodes and intercostal veins occupy the space between the spine and the lung, they cannot normally be recognized individually. In individuals with little fat, the interfaces, known as the paraspinal lines, may closely reflect the

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Figure 12.28 Right phrenic nerve as it passes over the surface of the right hemidiaphragm (arrows).

Figure 12.27 Retrosternal stripe (arrowheads) and inferior vena cava in lateral projection (arrow).

and oesophageal hiatuses. The median arcuate ligament connecting the two crura forms the anterior margin of the aortic hiatus, and the crura themselves form its lateral boundary. The oesophageal hiatus lies anterior to the aortic hiatus, and anterior to that lies the hiatus for the inferior vena cava, which is situated within the central tendon immediately beneath the right atrium. In most individuals, the diaphragm has a smooth domed shape, but a scalloped outline is also common. The angle of contact with the chest wall is acute and sharp, but blunting of this angle can be normal in athletes, because they can depress their diaphragm to a remarkable degree on deep inspiration. The normal right hemidiaphragm is found at about the level of the anterior portion of the sixth rib, with a range of approximately one interspace above or below this level34. In most people, the right hemidiaphragm is 1.52.5 cm higher than the left, but the two hemidiaphragms are at the same level in some 9% of the population. In a few normal individuals the left hemidiaphragm is up to 1 cm higher than the right. The normal excursion of the diaphragm is usually between 1.5 and 2.5 cm, though greater degrees of movement are not uncommon. Transabdominal ultrasound, which is capable of providing accurate real-time measurement of movement, shows a considerable normal range of between 2.0 and 8.6 cm, the mean excursion of the right hemidiaphragm on deep inspiration being 53 mm (sd 16.4) and that of the left being 46 mm (sd 12.4)35. Incomplete muscularization, known as eventration, is also common. An eventration is composed of a thin membranous sheet replacing what should be muscle. Usually it is partial, involving one-half to one-third of the hemidiaphragm. The lack of muscle manifests itself radiographically as elevation of the affected portion of the diaphragm, and the usual appear-

ance is one of a smooth hump on the contour of the diaphragm.Total eventration of a hemidiaphragm, which is much more common on the left than the right, results in elevation of the whole hemidiaphragm; on fluoroscopy hemidiaphragm movement is poor, absent, or paradoxical, and severe cases of congenital eventration cannot be distinguished from acquired paralysis of the phrenic nerve. A linear density arising from the lateral wall of the inferior vena cava (Fig. 12.28) is often seen coursing over the surface of the right hemidiaphragm.This line represents pleura and an envelope of fat investing the phrenic nerve, according to Berkman et al36, or the inferior phrenic artery and vein, according to Ujita et al37.

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